Impulse Control Behaviors Research Articles

Impulse Control Behaviors Affect One Fifth of Patients with Parkinson's Disease, Study Finds

Impulse Control Behaviors Affect One Fifth of Patients with Parkinson's Disease, Study Finds

Impulse control disorders in Parkinson disease and RBD: A longitudinal study of severity.

ObjectiveTo describe the prevalence, natural history, and risk factors for impulse control behaviors (ICBs) among people with Parkinson disease (PD), those with REM sleep behavior disorder (RBD), and controls.MethodsParticipants with early PD (within 3.5 years of diagnosis), those with RBD, and controls were clinically phenotyped and screened for ICBs longitudinally (with the Questionnaire for Impulsivity in Parkinson's Disease). ICB-positive individuals were invited for a semistructured interview, repeated 1 year later. The severity of the ICB was assessed with the Parkinson's Impulse Control Scale. Multiple imputation and regression models were used to estimate ICB prevalence and associations.ResultsData from 921 cases of PD at baseline, 768 cases at 18 months, and 531 cases at 36 months were included, with 21% to 25% screening positive for ICBs at each visit. Interviews of ICB screen–positive individuals revealed that 10% met formal criteria for impulse control disorders (ICD), while 33% had subsyndromal ICD (ICB symptoms without reaching the formal diagnostic criteria for ICD). When these data were combined through the use of multiple imputation, the prevalence of PD-ICB was estimated at 19.1% (95% confidence interval 10.1–28.2). On follow-up, 24% of cases of subsyndromal ICD had developed full symptoms of an ICD. PD-ICD was associated with dopamine agonist use, motor complications, and apathy but not PD-RBD. ICD prevalence in the RBD group (1%) was similar to that in controls (0.7%).ConclusionsICBs occur in 19.1% of patients with early PD, many persisting or worsening over time. RBD is not associated with increased ICD risk. Psychosocial drivers, including mood and support networks, affect severity.

Shifts in frontal asymmetry underlying impulsive and controlled decision-making

The frontal cortices are asymmetrically activated in impulsive and inhibitory action. However, no past work has examined shifts in frontal asymmetric activation during active impulse control or risk-taking behavior. The current study examined impulsive and controlled behavior in a behavioral risk-taking task (Balloon Analogue Risk Task) under alcohol or neutral cue exposure while EEG was recorded. Results revealed activity shifted towards greater relative left frontal activation on alcohol trials with impulsive behavior (balloon explosion) driven by reduced activation of the right inferior frontal gyrus. In contrast, activity from the first half to the second half of alcohol trials with successful impulse control (cash out) localized to reduced activation of the left inferior frontal gyrus. These findings suggest that shifting of right or left frontal asymmetry in inhibitory or impulsive behaviors stem from activation of the inferior frontal gyrus and reveal the importance of examining shifts in neural activity during behavioral processes.

Impulse Control Behaviors in Parkinson's Disease: Drugs or Disease? Contribution From Imaging Studies.

Impulse control behaviors (ICB) are recognized as non-motor complications of dopaminergic medications in patients with Parkinson's disease (PD). Compelling evidence suggests that ICB are not merely due to the PD-related pathology itself. Several risk factors have been identified, either demographic, clinical, genetic or neuropsychological. Neuroimaging studies have yielded controversial results regarding ICB correlates in PD and still it is not clear whether they can be triggered by the PD biology or the dopaminergic treatment stimulation. We provided an overview of the imaging studies that offered the most relevant insights into the debate about the role of drugs and disease in ICB pathophysiology. Understanding neural correlates and potential predisposing factors of these severe neuropsychiatric symptoms will be crucial to guide clinical practice and to foster preventive strategies.

The factors associated with impulse control behaviors in Parkinson's disease: A 2-year longitudinal retrospective cohort study.

IntroductionImpulse control behaviors (ICBs) are impulsive–compulsive behaviors often associated with dopamine replacement therapy in Parkinson's disease (PD). Although remission can occur in ICB, only four reports on the ratio of remission and the persistence of ICB have been published, and the associated factors with ICB remission or persistence have been little known. Therefore, we conducted a longitudinal assessment of the remission, persistence, and development of ICB and those associated factors in patients with PD.MethodsWe retrospectively investigated a PD database at Aomori Prefectural Central Hospital, Japan. One hundred and forty‐eight patients with PD who could be followed up for 2 years were enrolled. ICB was assessed using the Questionnaire for Impulsive–Compulsive Disorders in Parkinson's disease. Motor severity (Hoehn and Yahr scale and United Parkinson's Disease Rating Scale), cognitive function (Mini–Mental State Examination), and other clinical variables (sex, age, onset age, disease duration, olfactory dysfunction, and dyskinesia) and medications used to treat PD were assessed. Univariate analyses were performed.ResultsSeven patients were excluded because of the exclusion criteria, and 141 patients were analyzed. Thirty patients (21.3%) had ICB at baseline, and these patients also had significantly higher use of pergolide. The ICB remission rate was 60%, the ICB persistence ratio was 40%, and the ICB development ratio was 12.6% over 2 years. Statistically, younger age and pergolide use were associated with ICB persistence. Being male, having dyskinesia, and rotigotine, entacapone, zonisamide, and istradefylline use were associated with ICB development.ConclusionThis study suggests that younger age and pergolide use may be the new associated factors with ICB persistence and that entacapone, zonisamide, and istradefylline use may be associated with the development of ICB. Drug profiles and medication practices in Japan may explain the association of these factors with ICB.

Improvement of impulse control disorders associated with levodopa-carbidopa intestinal gel treatment in advanced Parkinson's disease.

Impulse control behaviors are a frequent comorbidity for patients with Parkinson's disease (PD). The objective of the present study was to evaluate the effectiveness levodopa-carbidopa intestinal gel (LCIG) therapy on impulse control disorders (ICDs) in patients with advanced PD. We conducted a multicenter, observational, and prospective (6months follow-up) study that included consecutive PD patients assigned to LCIG through routine medical practice. Patients completed visits at baseline, 1, 3, and 6months after percutaneous endoscopic gastrostomy procedure. The following outcomes were evaluated: presence and severity of ICDs and other neuropsychiatric disorders, sleep disturbances, patients' quality of life, and caregivers' burden. Sixty-two patients were included at baseline: mean age 72.2years (SD±7.0), 42% women. Median duration of PD symptoms was 13.5years (IQR 5.5-21.5) and median time with motor fluctuations was 5.0years (IQR 1.0-9.0). Treatment with LCIG infusion was associated with progressive and significant improvements in ICDs symptoms over the study period (64.4% reduction in the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's disease-Rating Scale score). Psychotic and other neuropsychiatric symptoms were also significantly reduced, and patients' sleep quality and psychosocial function improved. Caregivers' burden remained unchanged. There was a significant improvement in the daily "Off" time [7.4h (SD±4.0) vs 1.5h (SD±1.8); p<0.0001] at the end of follow-up, whereas duration of dyskinesias was not affected. ICDs significantly improved after 6-month LCIG treatment in a group of PD patients with mild-to-moderate neuropsychiatric disturbances.

Steroid 5α-reductase 2 deficiency leads to reduced dominance-related and impulse-control behaviors

The enzyme steroid 5α-reductase 2 (5αR2) catalyzes the conversion of testosterone into the potent androgen 5α-dihydrotestosterone. Previous investigations showed that 5αR2 is expressed in key brain areas for emotional and socio-affective reactivity, yet the role of this enzyme in behavioral regulation remains mostly unknown. Here, we profiled the behavioral characteristics of 5αR2 heterozygous (HZ) and knockout (KO) mice, as compared with their wild-type (WT) littermates. While male 5αR2 KO mice displayed no overt alterations in motoric, sensory, information-processing and anxiety-related behaviors, they exhibited deficits in neurobehavioral correlates of dominance (including aggression against intruders, mating, and tube dominance) as well as novelty-seeking and risk-taking responses. Furthermore, male 5αR2 KO mice exhibited reduced D2-like dopamine receptor binding in the shell of the nucleus accumbens – a well-recognized molecular signature of social dominance. Collectively, these results suggest that 5αR2 is involved in the establishment of social dominance and its behavioral manifestations. Further studies are warranted to understand how the metabolic actions of 5αR2 on steroid profile may be implicated in social ranking, impulse control, and the modulation of dopamine receptor expression in the nucleus accumbens.

Subthalamic stimulation and neuropsychiatric symptoms in Parkinson’s disease: results from a long-term follow-up cohort study

BackgroundReports on behavioural outcomes after subthalamic nucleus deep brain stimulation in Parkinson’s disease are controversial and limited to short-term data. Long-term observation in a large cohort allows a better counselling...

The rise and fall of impulse control behavior disorders

IntroductionImpulse control disorders (ICDs) are psychiatric disorders characterized by the failure to resist an impulse or by the temptation to perform an act that is harmful to oneself or to others. MethodsICDs, including pathological gambling, hypersexuality, compulsive eating and shopping, can occur as a complication of Parkinson's disease (PD) together with other behavioral disorders, including dopamine dysregulation syndrome. This review is based on a literature search updated to May 2017, focusing on the epidemiology, clinical features, and therapeutic options of ICDs associated with PD. ResultsStudies on the prevalence of ICDs confirm that they represent common phenomena associated with PD, with some centers reporting up to 40% of the PD population affected; the relative prevalence of the main ICDs shows significant variability, with a majority of the studies reporting that hypersexuality is the commonest one. Risk factors associated with the development of ICDs in PD were systematically evaluated, confirming the correlation between these disorders and male gender, younger age at PD onset and family history for addiction. ConclusionsWe will discuss the recent advances on the functional neuroanatomy, the role of dopamine-serotonin interactions and the cognitive profile associated with ICDs. Management of PD-related ICDs is still based on poor evidence, and this topic should be the object for future research

Loss of synaptic zinc transport in progranulin deficient mice may contribute to progranulin-associated psychopathology and chronic pain

Affective and cognitive processing of nociception contributes to the development of chronic pain and vice versa, pain may precipitate psychopathologic symptoms. We hypothesized a higher risk for the latter with immanent neurologic diseases and studied this potential interrelationship in progranulin-deficient mice, which are a model for frontotemporal dementia, a disease dominated by behavioral abnormalities in humans. Young naïve progranulin deficient mice behaved normal in tests of short-term memory, anxiety, depression and nociception, but after peripheral nerve injury, they showed attention-deficit and depression-like behavior, over-activity, loss of shelter-seeking, reduced impulse control and compulsive feeding behavior, which did not occur in equally injured controls. Hence, only the interaction of ‘pain x progranulin deficiency’ resulted in the complex phenotype at young age, but neither pain nor progranulin deficiency alone. A deep proteome analysis of the prefrontal cortex and olfactory bulb revealed progranulin-dependent alterations of proteins involved in synaptic transport, including neurotransmitter transporters of the solute carrier superfamily. In particular, progranulin deficiency was associated with a deficiency of nuclear and synaptic zinc transporters (ZnT9/Slc30a9; ZnT3/Slc30a3) with low plasma zinc. Dietary zinc supplementation partly normalized the attention deficit of progranulin-deficient mice, which was in part reminiscent of autism-like and compulsive behavior of synaptic zinc transporter Znt3-knockout mice. Hence, the molecular studies point to defective zinc transport possibly contributing to progranulin-deficiency-associated psychopathology. Translated to humans, our data suggest that neuropathic pain may precipitate cognitive and psychopathological symptoms of an inherent, still silent neurodegenerative disease.

Personality, dopamine, and Parkinson's disease: Insights from subthalamic stimulation.

Subthalamic stimulation improves the motor and neuropsychiatric symptoms of Parkinson's disease. However, the impact of this treatment on impulse control and personality is the subject of heavy debate. The objective of this study was to investigate personality changes after subthalamic stimulation. Using Cloninger's biosocial model, we assessed personality in 73 Parkinson's disease patients before and 12 months after subthalamic stimulation accompanied by a drastic reduction in dopaminergic medication. Changes in psychobehavioral symptoms were measured using a battery of validated clinical scales (apathy, depression, anxiety, hyperemotionality, mania, psychosis, punding, and impulse control behaviors). One year after surgery, the harm avoidance personality domain total score increased compared with the baseline (+2.8; 34 patients; P < 0.001), as did 3 of its 4 subdomains: anticipatory worry (+0.7; 10 patients; P = 0.005), shyness (+0.6; 7 patients; P = 0.03), and fatigability (+1.1; 10 patients; P = 0.0014). Evolution of the shyness personality trait correlated with the decrease in dopaminergic medication. Total scores in the other personality domains remained unchanged, except for extravagance, a subdomain of novelty seeking, and persistence, a subdomain of reward dependence, which both decreased following surgery (-0.3; 7 patients; and -0.6; 9 patients; P = 0.03 and P = 0.0019, respectively). Although apathy increased, other psychobehavioral symptoms, including impulse control behaviors and neuropsychiatric nonmotor fluctuations, improved. Depression and anhedonia remained stable. Scores in hypodopaminergia and neuropsychiatric nonmotor OFF correlated with harm avoidance. Scores in hyperdopaminergia and neuropsychiatric nonmotor ON correlated with novelty seeking. When subthalamic stimulation is applied in Parkinson's disease, significant changes in personality traits are observed, which may be related to postoperative tapering of dopaminergic treatment. © 2017 International Parkinson and Movement Disorder Society.

Prevalence and Correlates of Behavioral Disorders in Old Age Subjects with Cognitive Impairment: Results from the ReGAl Project.

Presence of behavioral and psychological symptoms of dementia (BPSD) is very common in subjects with cognitive impairment, representing an important determinant of disease progression, institutionalization, and worse prognosis. Knowledge of the prevalence and correlates of BPSD in community-living old subjects with cognitive impairment is limited so far, but it is essential for establishing specifically tailored care and cure in such a vulnerable population. With this study, we aimed at investigating, in a large sample of old age subjects with cognitive impairment, BPSD prevalence and correlates including the main demographic, clinical, and socio-environmental characteristics. Data were gathered from the ReGAl project (Rete Geriatrica Alzheimer; Geriatric Network on Alzheimer's disease), a large longitudinal Italian multicentric clinical-based study, promoted by the Italian Society of Gerontology and Geriatrics (SIGG). We evaluated data from 4,157 old-age subjects affected by mild cognitive impairment (MCI) (541; 13%) or dementia (3616; 87%). 85.2% of all the population presented with at least one BPSD. Using a factor analysis, we identified four factors of BPSD: psychotic, affective, maniac, and impulse control behaviors. Logistic regression analyses revealed that among the main demographic, clinical, and socio-environmental aspects considered, only comorbidity was associated with all factors, independently of multiple covariates. Identification of BPSD is crucial in everyday clinical practice and necessary to develop specific interventions and to define appropriate outcomes in their management. BPSD occur in a complex psychopathological context, influenced by several demographic and environmental factors that must be taken into account for a correct diagnosis and treatment.

Impulse control behaviors and subthalamic deep brain stimulation in Parkinson disease

To determine the clinical and demographic correlates of persistent, remitting, and new-onset impulse control behaviors (ICBs) before and after subthalamic deep brain stimulation (STN-DBS) in Parkinson's disease (PD). We compared the pre- and post-surgical prevalence of ICBs, classified as impulse control disorders (ICD), dopamine dysregulation syndrome (DDS), and punding in 150 consecutive PD STN-DBS-treated patients and determined the association with motor, cognitive, neuropsychological, and neuropsychiatric endpoints. At baseline (before STN-DBS), ICBs were associated with younger age (p=0.045) and male gender (85%; p=0.001). Over an average follow-up of 4.3±2.1years of chronic STN-DBS there was an overall trend for reduction in ICBs (from 17.3 to 12.7%; p=0.095) with significant improvement in hypersexuality (12-8.0%; p=0.047), gambling (10.7-5.3%; p=0.033), and DDS (4.7-0%; p<0.001). ICB remitted in 18/26 patients (69%) and persisted in 8/26 (31%); the latter group was characterized by higher levodopa equivalent daily dose. Patients who developed a new-onset ICB during follow-up (n=11/150) were characterized by younger age (p=0.042), lower dyskinesia improvement (p≤0.035), and a gender distribution with higher prevalence of women (p=0.018). In addition, new-onset ICB was more common among patients with borderline, schizoid, and/or schizotypal traits of personality disorders; persistent ICB in those with obsessive-compulsive traits. PD-related ICBs exhibit a complex outcome after STN-DBS, with a tendency for overall reduction but with age, gender, dopaminergic therapy, and neuropsychiatric features exerting independent effects.

P.1.h.004 - A new model of impulsivity, social interactions and preference of alcohol in mice living in groups

Affective and cognitive processing of nociception contributes to the development of chronic pain and vice versa, pain may precipitate psychopathologic symptoms. We hypothesized a higher risk for the latter with immanent neurologic diseases and studied this potential interrelationship in progranulin-deficient mice, which are a model for frontotemporal dementia, a disease dominated by behavioral abnormalities in humans. Young naïve progranulin deficient mice behaved normal in tests of short-term memory, anxiety, depression and nociception, but after peripheral nerve injury, they showed attention-deficit and depression-like behavior, over-activity, loss of shelter-seeking, reduced impulse control and compulsive feeding behavior, which did not occur in equally injured controls. Hence, only the interaction of ‘pain x progranulin deficiency’ resulted in the complex phenotype at young age, but neither pain nor progranulin deficiency alone. A deep proteome analysis of the prefrontal cortex and olfactory bulb revealed progranulin-dependent alterations of proteins involved in synaptic transport, including neurotransmitter transporters of the solute carrier superfamily. In particular, progranulin deficiency was associated with a deficiency of nuclear and synaptic zinc transporters (ZnT9/Slc30a9; ZnT3/Slc30a3) with low plasma zinc. Dietary zinc supplementation partly normalized the attention deficit of progranulin-deficient mice, which was in part reminiscent of autism-like and compulsive behavior of synaptic zinc transporter Znt3-knockout mice. Hence, the molecular studies point to defective zinc transport possibly contributing to progranulin-deficiency-associated psychopathology. Translated to humans, our data suggest that neuropathic pain may precipitate cognitive and psychopathological symptoms of an inherent, still silent neurodegenerative disease.

The high prevalence of impulse control behaviors in patients with early-onset Parkinson's disease: A cross-sectional multicenter study

IntroductionIn Parkinson's disease patients, impulse control disorders (ICDs) have been associated with younger age and early disease onset, yet the prevalence of ICDs in early-onset Parkinson's disease (EOPD) patients has yet to be studied. Thus, we set out to compare the prevalence of impulse control behaviors (ICBs) in a cohort of EOPD patients with that in age and gender matched healthy controls (HCs), as well as to analyze the association of these symptoms with the use of dopaminergic drugs and other clinical or demographic factors. MethodsA cross-sectional, multicenter study was carried out on patients recruited from outpatient Movement Disorder Clinics, assessing ICBs using the short form of the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease (QUIP). In addition, depression and quality of life (QoL) were measured, along with other demographic and clinical variables. ResultsOf the 87 EOPD patients, 49 (58.3%) displayed an ICB, as did 28 of the 87 HCs (32.9%; p=0.001). Most of the EOPD patients that displayed an ICB (91.8%) were medicated with a dopamine agonist (DA) and accordingly, DA treatment was associated with a 7-fold increased risk of developing an ICB. Patients with ICBs had a higher depression score and a worse QoL. ConclusionsICBs are much more prevalent in EOPD patients than in HCs and they are associated with DA intake, depression and a worse QoL.

A European multicentre survey of impulse control behaviours in Parkinson's disease patients treated with short- and long-acting dopamine agonists.

Impulse control disorders (ICDs) in Parkinson's disease (PD) are associated primarily with dopamine agonist (DA) use. Comparative surveys of clinical occurrence of impulse control behaviours on longer acting/transdermal DA therapy across age ranges are lacking. The aim of this study was to assess the occurrence of ICDs in PD patients across several European centres treated with short- or long-acting [ropinirole (ROP); pramipexole (PPX)] and transdermal [rotigotine skin patch (RTG)] DAs, based on clinical survey as part of routine clinical care. A survey based on medical records and clinical interviews of patients initiating or initiated on DA treatment (both short- and long-acting, and transdermal) across a broad range of disease stages and age groups was performed. Four hundred and twenty-five cases were included [mean age 68.3 years (range 37-90), mean duration of disease 7.5 years (range 0-37)]. ICD frequencies (as assessed by clinical interview) were significantly lower with RTG (4.9%; P < 0.05) compared with any other assessed DAs except for prolonged release PPX (PPX-PR). The rate of ICDs for PPX-PR (6.6%) was significantly lower than for immediate release PPX (PPX-IR) (19.0%; P < 0.05). Discontinuation rates of DA therapy due to ICDs were low. Our data suggest a relatively low rate of ICDs with long-acting or transdermal DAs, however these preliminary observational data need to be confirmed with prospective studies controlling for possible confounding factors.

Parkinson's Impulse-Control Scale for the Severity Rating of Impulse-Control Behaviors in Parkinson's Disease: A Semistructured Clinical Assessment Tool.

BackgroundImpulse‐control behaviors (ICBs) are increasingly recognized in Parkinson's disease (PD) as drug‐related effects of dopaminergic mediation that occur in 15% to 35% of patients with PD. The authors describe the design and evaluation of a new, clinician‐rated severity scale for the assessment of syndromal and subsyndromal forms of impulse‐control disorders (ICDs), simple (punding) and complex (hobbyism) repetitive behaviors, and compulsive overuse of medication (dopamine dysregulation syndrome).MethodsThe Parkinson's Impulse‐Control Scale (PICS), the first PD‐specific, semistructured interview to cover the full range of PD‐related ICBs, is described along with initial evidence on its clinimetric properties including interrater reliability, discriminant validity and sensitivity to change. A convenience sample of PD patients with ICBs and those without were administered a semistructured interview (n = 92).ResultsThe scale distinguished between those with and without clinically detected ICBs and between patients with syndromal ICD and subsyndromal ICB (receiver operating characteristic areas under the curve, 92%–95%). Cutoff values were suggested, and substantial agreement was reported on weighted kappa (Κ) values for clinician‐clinician rating of severity (Κ = 0.92). Significant improvements were detected on the scale after a randomized controlled trial of cognitive‐behavioral therapy and medication adjustment (t[22] = 5.47; P < 0.001).ConclusionsThe PICS appears to be a reliable measure of the full range of PD ICBs with good levels of interrater reliability. It may provide a useful measure to assess the severity of ICBs and monitor change in clinical and research settings; although, given the specialized centers used for recruitment of this sample, further psychometric evaluation is required.

Defining the phenotype of restless legs syndrome/Willis-Ekbom disease (RLS/WED): a clinical and polysomnographic study.

Clinical features variability between familial and sporadic restless legs syndrome/Willis-Ekbom disease (RLS/WED) has been previously reported. With this retrospective cohort study, we aimed to determine the clinical and polysomnographic characteristics of 400 RLS/WED patients. Patients with familial RLS/WED were significantly younger than sporadic RLS/WED, while clinical and polysomnographic characteristics were similar in both groups. No difference was found for the age-at-onset between idiopathic and secondary RLS/WED. Periodic limb movements (PLM) index and REM sleep time were higher in idiopathic RLS/WED. Time of onset of symptoms was in the evening or at bedtime in 28.04 and 37.80% of patients, respectively, while in 21.34% of patients onset was more than 1 h after sleep onset. Impulse control and compulsive behaviours (ICBs) were found in 13.29% patients on dopamine agonist therapy. Our analyses support the hypothesis that patients with a familial history of RLS/WED may have a genetic component. Nevertheless, the dichotomy between early and late onset disease seems to be less sharp than previously reported. A large proportion of RLS/WED patients can have atypical features, therefore making the diagnosis challenging. Some cases can be missed even when the patient refers to a sleep specialist, as revealed by the partial absence of daytime symptoms, the high comorbidity with insomnia and other sleep complaints and the high percentage of symptoms beginning after sleep onset. This draws attention on the importance of a careful evaluation of the patient, to recognize potentially treatable secondary forms of RLS/WED.

Parental alienation: the impact on men's mental health.

Parental alienation is defined as a mental state in which a child, usually one whose parents are engaged in a high-conflict separation or divorce, allies himself strongly with one parent (the preferred parent) and rejects a relationship with the other parent (the alienated parent) without legitimate justification. Parental alienation may affect men's mental health: a) parental alienation negatively influences mental health of male children and adolescents who are victims of parental alienation. Alienated children/adolescents display guilt, sadness, and depressed mood; low self-esteem and lack of self-confidence; distress and frustration; lack of impulse control, substance abuse and delinquent behavior; separation anxiety, fears and phobias; hypochondria and increased tendency to develop psychosomatic illness; suicidal ideation and suicide attempt; sleep and eating disorders; educational problems; enuresis and encopresis; b) parental alienation negatively affects the mental health of adult men who were victims of parental alienation when they were children and/or adolescents. Long-term effects of parental alienation include low self-esteem, depression, drug/alcohol abuse, lack of trust, alienation from own children, divorce, problems with identity and not having a sense of belonging or roots, choosing not to have children to avoid being rejected by them, low achievement, anger and bitterness over the time lost with the alienated parent; c) parental alienation negatively influences mental health of men who are alienated from their children. Fathers who have lost some or all contact with their children for months or years following separation or divorce may be depressed and suicidal.

Developments in impulse control behaviours of Parkinson's disease.

Impulse control behaviours (ICBs) are a frequent comorbidity for patients with Parkinson's disease. They consist of impulse control disorders, dopamine dysregulation syndrome, and punding. The field continues to evolve in the understanding of impulsivity and assessment of risk factors in the development of these behaviours and their appropriate management in patients with Parkinson's disease. Impulsivity is a multifaceted concept that is surprisingly common in untreated patients with Parkinson's disease. The incidence of ICBs increases with demographic, clinical, and biochemical risk factors. Treatments rely on reduction of dopamine agonists with exception of cognitive behavioural therapy and possibly repetitive transcranial magnetic stimulation. Reduction of dopamine agonist dose is the mainstay of treatment of ICBs. Other forms of dopaminergic treatment such as deep brain stimulation or jejunal infusion are alternative treatments but may be complicated by dopamine agonist withdrawal syndrome. Other therapies show promise but data are insufficient to suggest their regular use.